By filing a claim, the policy holder requests coverage. The policy holder is supposed to be reimbursed by their insurance carrier if it is outlined in the terms of the policy. If a claim is denied, the carrier must explain why it was denied in writing. When an insurer denies a health claim, the policy holder has the right to fight back. This is done through an appeal of the claim. There are two methods to appealing a health insurance claim. These two methods are called internal and external.
Here is how to appeal a claim internally:
- Send required information. Send all the required information to the insurer. Then the policy holder must submit any additional information, such as a letter from a doctor. After this, the Consumer Assistance Program will file an appeal on the policy holder's behalf. The policy holder must file an internal appeal within 180 days of receiving a denial letter.
Filing externally is a two-step process:
- File a written request. Within 60 days of receiving a denial letter, the policy holder must file a written request to receive an external review.
- External reviewer makes final decision. The party who performs the external review will decide whether the matter is in the policy holder's favor or in the insurance company’s favor. By law, the insurance company must abide by the decision made by the party who carries out the external review.